New Patient Health and Wellness Survey

Welcome to our office! We constantly strive to make sure we are meeting

your health and wellness goals. Please help us serve you better by letting us

know what is important to you. We want to customize your care in our office.

I am interested in the following (check all that apply):

□ Pain relief only

□ Correction and maintenance of my problem

□ Weight loss

□ Healthy eating for disease prevention

□ Exercise/strength/flexibility programs

□ Family wellness care

□ Other _________________________________________________

Thank you! It is a pleasure to be a part of your Healthcare Team!

PATIENT INFORMATION: INSURANCE INFORMATION:

Today’s Date: ________________________

Name: __________________________________

Address: ________________________________

City:________________ State:______Zip:_____

Home Phone: ____________________________

Cell Phone: ______________________________

Business Phone: __________________________

E-mail address: ___________________________

Sex: Marital Status: ________

Social Security #: _________________________

Date of Birth: ____________________________

Occupation/School: _______________________

Employer: _______________________________

Emergency Contact :_______________________

Phone: __________________________________

Relationship to Patient: _____________________

Primary Care Physician: ____________________

Address: ________________________________

Whom may we thank for referring you?

________________________________________

ACCIDENT INFORMATION:

Is condition due to an ACCIDENT?

Type of Accident:

Date of Accident: _______________________

To whom have you reported this accident?

other__________________

Insurance Carrier: ________________________

Address: _______________________________

City: ______________ State: ____ Zip: ________

Telephone: ______________________________

Policy #: ________________________________

Effective Date:___________________________

Policyholder’s Name:_______________________

Relationship to Patient: ____________________

Policyholder’s Social Security #______________

Policyholder’s Date of Birth: ________________

Employer: _______________________________

SECONDARY INSURANCE:

Name:__________________________________

Address: ________________________________

Telephone: ______________________________

Effective Date: ___________________________

Policy #:_________________________________

Policyholder: ____________________________

Policyholder’s Social Security #:______________

Policyholder’s Date of Birth:_________________

ATTORNEY INFORMATION (If applicable):

Attorney Name:___________________________

Address:_________________________________

Telephone Number: ______________________

1

ADVANCED WELLNESS Initial Medical Intake PIP

Date: ____________________

Name:___________________________ DOB:____________________

Age: ____________________________ REFERRING PHYSICIAN: ________________________

What is the reason for your visit today:__________________________________________________________

PAIN DRAWING

/// STABBING XXX BURNING *** TINGLING NUMBNESS +++ ACHING

Where is your pain:

Rate your pain level from 0-10 (0=no pain, 1-3=mild, 4-6=moderate, 7-9=severe, 10=worst pain possible)

Neck Pain: 0 1 2 3 4 5 6 7 8 9 10

Midback Pain: 0 1 2 3 4 5 6 7 8 9 10

Low Back Pain: 0 1 2 3 4 5 6 7 8 9 10

______ Joint Pain: 0 1 2 3 4 5 6 7 8 9 10

When did your pain/symptoms begin:____________________________

Where you the: Driver____ Passenger_____ Pedestrian_______

Where you wearing your seat belt? Yes No

What type of vehicle were you in: __________________________________

What type of vehicle was the other vehicle: ______________________________

How did the accident happen: _____________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Where did the accident occur: _____________________________________________________________________

2

Did any part of your body hit the interior of the vehicle? _______________________________________________

Did you lose consciousness? YES NO For how long?___________________________________________

Did the air bags deploy? YES NO

Did you go to the emergency room? YES NO, Where?_______________________________________

Did you go: Right after the accident_____________ The next day____________ Other_________

How did you go to the ER? By Ambulance Other:_________________________________________

Where you discharged home the same day? YES NO

Any motor vehicle accidents in the past? _________ If yes explain:___________________________________

Other symptoms associated with pain: Numbness Tingling Muscle Spasm Weakness

Headache Dizziness Difficulty Walking Clicking/Grinding

Bowel/bladder leakage Decreased Movement Joint Swelling Joint Stiffness

Is the pain: Dull Aching Sharp / Stabbing Throbbing Burning Pins/Needles

Tight / Cramping Soreness Shooting

Does the pain: Radiate down the RIGHT or LEFT arm, down to the SHOULDER / ELBOW / HAND

Radiate down the RIGHT or LEFT leg down to the HIP / THIGH / KNEE / ANKLE / TOES

Is the pain: Constant Intermittent (comes and goes)

Is the pain getting: BETTER WORSE STAYING THE SAME FLUCTUATING

What makes the pain worse: Standing Sitting Walking Movement Lying down

Bending forward Bending Backwards Lifting Bowel Movement

Cough/Sneeze Hot weather Cold weather Other:________________________

What makes the pain better: Standing Sitting Walking Movement Lying down

Rest Massage Elevating area Ice Heat Medications Other:___________

What treatments have you had for the pain: Physical therapy Chiropractic Acupuncture

Massage Trigger Point Injection Epidural Injection Facet Injections Joint Injections

What medications have you taken for the pain: _______________________________________________________

Does the pain affect your quality of life and/or physical functioning? YES NO

How is your sleep: Good Fair Poor

Any other Neck, Back, or Joint injuries in the past? ____________________________________________________

Have you had any tests in past 5 years: MRI CT Xrays Bone Density Bone Scan Other:__________

Where was this done:______________________________________________________________________

Past Health History/Medical Conditions: _____________________________________________________________

3

_______________________________________________________________________________________________

Past Surgeries / Procedures: _______________________________________________________________________

_______________________________________________________________________________________________

Drug/Environmental Allergies: _____________________________________________________________________

Current Medications: _____________________________________________________________________________

_______________________________________________________________________________________________

Family History: __________________________________________________________________________________

Social History: Current Alcohol intake: _________________ Past Alcoholism? _____________

Tobacco Use: ________ How much? _______________ Drug use: _____________________

Any past drug abuse or addiction issues? _____________ Past drug rehab?_______________

Occupation:_______________________________; Full-time___ Part-time_______

If unemployed or on leave what was date you last worked: _________________________________

Married____ Single____ Divorced____ Widowed_____; Do you have children?_________

Level of education: High School___ College____ Graduate School____ Other:___________

Do you have any of the following: (circle all that apply)

GENERAL: Changes in appetite or weight, Fatigue, Fever, Chills, Night Sweats, Weakness

MS: Bone Pain, Joint Stiffness, Red/Swollen joints, Deformed joints

Skin: Rashes, Lumps, Acne, Dryness, Discoloration, Changes in hair / nails / moles, Itching, Recurrent skin

infections, Skin ulcers, Hypersensitivity

HEENT: Head injury, Visual changes, Double vision, Blurred vision, Earache, Eye pain, Glaucoma, Cataracts,

Hearing changes, Runny nose, Toothaches, Hoarseness, Dentures, Ringing in ears, Vertigo, Dizziness,

Frequent colds, Nose bleeds

Respiratory: Cough, Coughing up blood, Shortness of breath, Wheezing, Choking or Gasping for air at night,

Exposure to Tuberculosis

Cardiovascular: Chest pain, Irregular heartbeat, Palpitations

Gastrointestinal: Abdominal pain, Changes in bowel movements, Constipation, Diarrhea, Heartburn, Blood in

stools, Black stools, Nausea, Vomiting, Leakage of stool

Urinary: Pain or burning with urination, Sudden urge to urinate, Trouble starting urination stream, Leaking of

urine, Pain in sides, Change in urination

Genital/Reproductive: Sexual difficulties, Painful sexual intercourse

Neurological: Seizures, Tremors, Memory loss

Endocrine: Cold intolerance, Heat intolerance, Excessive sweating, Excessive urination, Excessive thirst

Psychiatric: Anxiety, Sleep disturbance, Irritability, Depression, Mood swings, Suicide thoughts or actions

Height: _____feet, ________inches Weight:____________________lbs

I have completed this form & carefully reviewed its contents. I attest to the accuracy & correctness of the information

Patient or Guardian signature:________________________________________ Date:__________________

Reviewed by: __________________________________

NOTIFICATION OF COMMENCEMENT OF MEDICAL TREATMENT FORM

(TWENTY ONE DAY NOTICE)

(N.J.A.C. 11:3-25, et seq)

TREATING HEALTH CARE PROVIDER INFORMATION:

NAME: ____________________________________________________________

ADDRESS: ____________________________________________________________

____________________________________________________________

PHONE: _______________________________FAX: _______________________

PATIENT INFORMATION:

NAME: ___________________________________________________________

ADDRESS: ___________________________________________________________

___________________________________________________________

INSURER INFORMATION:

NAME: ___________________________________________________________

ADDRESS: ___________________________________________________________

___________________________________________________________

POLICY NUMBER: __________________________________________

CLAIM NUMBER: __________________________________________

DATE OF ACCIDENT: __________________________________________

FIRST TREATMENT DATE: __________________________________________

ASSIGNMENT OF PIP MEDICAL BENEFITS FORM

PATIENT AUTHORIZATION:

I am the PATIENT described above and I authorize and direct the INSURER described

above to pay the TREATING HEALTH CARE PROVIDER described above, the amount

due under the terms of the policy described above for any PIP medical benefits rendered

by the TREATING HEALTH CARE PROVIDER described above an/or all staff

associated with that office.

I further authorize the TREATING HEALTH CARE PROVIDER described above to file

a DEMAND FOR ARBITRATION (PIP) against the INSURER described above for any

PAYMENT DISPUTE for PIP medical benefits rendered by the TREATING HEALTH

CARE PROVIDER described above and/or all staff associated with that office.

SIGNED: _____________________________________ DATE: ________________

PAYMENT DISPUTE shall include a denial and/or non-payment by the INSURER

described above for PIP medical benefits rendered by the TREATING HEALTH CARE

PROVIDER described above and/or all staff associated with that office. PAYMENT

DISPUTE shall also include a denial and/or refusal to authorize by the INSURER named

above any recommended medical benefits as part of the TREATMENT PLAN of the

TREATING HEALLTH CARE PROVIDER described above and/or all staff associated

with that office.

SIGNED: _____________________________________ DATE: _______________

TREATING HEALTH CARE PROVIDER REPRESENTATION:

I am the TREATING HEALTH CARE PROVIDER described above and provide the

following representations to the INSURER named above in order for the ASSIGNMENT

OF BENEFITS executed by the PATIENT named above to be honored. Specifically:

All requirements of the DECISION POINT REVIEW PLAN and/or

PRECERTIFICATION PLAN of the INSURER named above that are in accordance with

the regulations promulgated by the Department of Banking and Insurance (DOBI) shall

be complied with; and

In the event of a failure to comply with the aforementioned requirements, the PATIENT

described above will not be held financially liable for any imposed penalty.

It is understood and an INSURER may apply to DOBI pursuant to N.J.A.C. 11:3-4.9 (a)

for “approval policy forms that include reasonable procedures for restrictions on the

assignment of personal injury protection benefits, consistent with the efficient

administration of the coverage.” As such please provide me within ten days of receipt of

this form with any documentation required to effectuate the intent of the patient described

above. Failure to provide any documentation will be construed as a constructive

acceptance of this form and the intent of the patient described above.

Signed (AWC) _____________________________________ Date: _________________

APPOINTMENT AND CANCELLATION POLICY

At Advanced Wellness, our goal is to provide quality care in a timely manner. We have implemented an appointment/cancellation policy which enables us to better utilize available appointments for our patients in need of care. Scheduled Appointments

To schedule an in-office appointment by telephone, please call: 732-431-2155and select option #3 To schedule a surgery center/procedure appointment please call: 732-431-2155 and select option #5 . Cancellation of Appointments

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book. Please be courteous and call the office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. Surgical Appointments Cancellation of scheduled surgeries requires 24 hours’ notice. Because of the necessary time, supplies and equipment allotted for surgical procedures, any cancellation not made prior to 24 hours will be subject to a fee of $100.00 ($50.00 for Iovera patients). If you are a “no show” after confirming your appointment, you will be subject to a $250.00 fee. This fee will not be billed to insurance and is payable prior to your next appointment. Lateness

Please be courteous of all fellow patients and be on time for your appointments. If you are running late, kindly call the office and we will advise as to whether you should come in. If you are more than 10 minutes late, it is possible that you may not be seen and will be scheduled at the next available appointment time. No Show Policy

A “no show” is someone who misses an appointment without canceling it in advance. No-shows inconvenience those individuals who need access to care in a timely manner. A failure to present at the time of a scheduled in-office appointment will be recorded in the patient’s chart as a

“no show”. Three “no shows” may result in the temporary suspension of services.

I have read, understand and agree to this policy:

Patient Signature:____________________________________ Date: __________________

ASSIGNMENT OF BENEFITS/ERISA AUTHORIZATION FORM

ADVANCED WELLNESS CENTER

Financial Responsibility

I have requested professional services from ADVANCED WELLNESS (“Provider”) on behalf of myself and/or

my dependents, and understand that by making this request, I am responsible for all charges incurred

during the course of said services. I understand that all fees for said services are due and payable on the

date services are rendered and agree to pay all such charges incurred in full immediately upon presentation

of the appropriate statement unless other arrangements have been made in advance.

Assignment of Insurance Benefits

I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to

Provider. I certify that the health insurance information that I provided to Provider is accurate as of the

date set forth below and that I am responsible for keeping it updated.

I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or

its administrator) listed on the current insurance card I provided to Provider in good faith. I also hereby

instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my

dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct

and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to

myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its

administrator) to make out the check to me and mail it directly to Provider.

I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my

bills for professional services from Provider are paid in full.

Authorization to Release Information

I hereby authorize Provider to: (1) release any information necessary to my health benefit plan (or its

administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of

examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance

claims. This order will remain in effect until revoked by me in writing.

ERISA Authorization

I hereby designate, authorize, and convey to Provider to the full extent permissible under law and under

any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act on

my behalf in connection with any claim, right, or cause of action that I may have under such insurance

policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right or

cause of action in connection with said insurance policy and/or benefit plan (including but not limited to

the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in

29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I

received from Provider and, to the extent permissible under the law, to claim on my behalf such benefits,

claims, or reimbursement, and any other applicable remedy, including fines. Furthermore, the Provider

shall have every right and I hereby authorize the Provider to request a Summary Plan Description (“SPD”)

on my behalf.

A photocopy of the Assignment/Authorization shall be as effective and valid as the original.

________________________________________________ _______________________________

Patient Date

________________________________________________ ________________________________

Policyholder/Insured Date

17 North Main Street, Marlboro, NJ 07746 Tel: (732) 431-2155; Fax: (732) 431-2889

Office Policies

Our office is a zero balance office. All services including copayments must

be paid for at the time of service unless other arrangements have been made.

All missed appointments must be made up according to your care plan.

Please call 24 hours in advance if you need to reschedule your appointment.

ASSIGNMENT OF BENEFITS/HIPAA GUIDELINES

I certify that I, and /or my dependent(s) have insurance coverage with

________________________________________ and assign directly to Advanced Wellness

Center all insurance benefits, if any, otherwise payable to me for services rendered. I authorize

the use of my signature on all insurance submissions.

The above-named facility may use my health care information and may disclose such

information to the above-named insurance company(ies) and their agents for the purpose of

obtaining payment for services and determining insurance benefits or the benefits payable for

related services.

I am aware that Advanced Wellness Center (AWC) will abide by the HIPAA regulations for the

purpose of keeping my records confidential and only upon my written consent will my records

be allowed to leave AWC.

Signature of patient, parent or guardian Date

Print Name of patient, parent or guardian Date

Thank you and welcome to our office!

17 North Main Street, Marlboro, NJ 07746 Tel: (732) 431-2155; Fax: (732) 431-2889

X-RAY CONSENT FORM

I, _______________________________________, give consent to have an x-ray examination performed

should x-rays be required to diagnose or assist in the diagnosis of my condition.

For Female Patients:

To the best of my knowledge I am not currently pregnant nor am I trying to become pregnant. I

understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is

possible to injure the fetus. I have been advised that the 10 days following onset of a menstrual period

are generally considered to be safe for x-ray exams.

With these factors in mind, I give informed consent to have an x-ray examination performed on me and

hereby release this facility and any owner or representative from any responsibility.

Patient Name: __________________________________

Patient Signature: _______________________________

AWC Representative: ____________________________

Date: _________________________________________

17 North Main Street, Marlboro, NJ 07746 Tel: (732) 431-2155; Fax: (732) 431-2889

AUTHORIZATION OF RELEASE MEDICAL INFORMATION TO FAMILY MEMBERS Name of Patient: _________________________________________________________________ Date of Birth: ________________________________________ I hereby authorize medical providers and personnel of Advanced Wellness Center of Marlboro to discuss my protected health information with: ______________________________________ _____________________________________ (Relationship) (Name) ______________________________________ _____________________________________ (Relationship) (Name) ______________________________________ _____________________________________ (Relationship) (Name) I understand that certain information cannot be released without specific authorization as required by state or federal law. By initialing the lines below, I authorize the release of the following protected or sensitive information: ____ Information regarding the patient’s diagnosis and treatment for HIV/AIDS ____ Psychotherapy notes from a Psychiatrist or Psychotherapist ____ Treatment for alcohol or drug abuse reports This authorization shall be in force and in effect from ______________ until ________________ at which time this authorization to use or disclose this protected health information expires. Unless specified above, this authorization will expire 365 days from the date of signing. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization.

Signature of Patient

Date

Headaches _________Allergies _________Neck Pain _________TMJ _________ _________Thyroid Condition _________Shoulder Pain _________Upper Back Pain _________Mid Back Pain _________Elbow / Arm Pain _________Gastrointestinal Issues _________Fatigue _________Low Back Pain _________Wrist/Hand Pain _________Numb/Tingling Hands _________Hip Pain _________Weight Concerns _________Thigh Pain _________ Knee Pain _________Calf Pain _________ Shin Pain _________ Autoimmune Conditions _________Hormonal Issues _________Diabetes _________Foot / Ankle Pain _________Numb/Tingling Feet _________Balance Problems _________

Please check all applicable conditions. Then, rate your pain, stiffness, weakness or discomfort on a scale of 1-10. 1 = Not Concerned and 10 = Extremely Concerned.

Name: Date:

Rate On Scaleof 1-10

www.advanced-wellness.net17 North Main Street • Marlboro, NJ 07746 | 732-431-2155

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